RESEARCH FINDINGS #37: Ever Uninsured During the Calendar Year, 2013-2015: Estimates of Non-Elderly Adults Ever Uninsured During Each Calendar Year, by Selected Population Sub-groups and State Medicaid Expansion Status

August 2017

Brandy J. Lipton, Ph.D. and Jessica P. Vistnes, Ph.D.

Highlights

The percentage of non-elderly adults, ages 18-64, uninsured at any time during the calendar year ("ever uninsured") declined from 30.8 percent (58.4 million adults) in 2013 to 27.8 percent (53.1 million adults) in 2014 and then to 23.5 percent (45.1 million adults) in 2015.

In Medicaid expansion states, in 2014 and then again in 2015, "ever uninsured" rates declined for adults without a high school diploma (from 48.1 percent in 2013 to 43.9 percent in 2014 and 36.9 percent in 2015).

In non-expansion states, "ever uninsured" rates for adults without a high school diploma did not decline significantly and remained above 50 percent from 2013 to 2015.

In Medicaid expansion states, "ever uninsured" rates declined in 2014 and then again in 2015 for Hispanic adults, falling from 48.8 percent in 2013 to 44.9 percent in 2014 and 35.5 percent in 2015. In non-expansion states, "ever uninsured" rates for Hispanic adults declined between 2014 and 2015, but remained over 50 percent.

Introduction

In 2014, new sources of insurance coverage became available for previously uninsured adults.
These
include
premium
tax
credits
for
low
and
middle-income
adults to
purchase
private insurance in
Marketplaces and the potential for states to
expand Medicaid eligibility to include adults with incomes up to 138 percent of the federal poverty line.
By the end of 2014, 26 states and the District of Columbia had expanded their Medicaid programs.
Three additional states opted to implement the Medicaid expansion by the end of 2015. In addition, individual and employer mandates
were introduced in 2014 and 2015 that established
financial incentives promoting coverage.

Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC), this Research Findings examines changes from 2013 to 2015 in the percentage of non-elderly adults who were uninsured for at least one month (the "ever uninsured rate") during each calendar-year. Note that the "ever uninsured rate" estimates presented in this Findings are higher than the MEPS estimates of non-elderly adults uninsured throughout the calendar year (the "calendar year uninsured rate") which are presented in Research Findings #35. This is because individuals uninsured for all 12 months in a calendar year are a subset of those who are uninsured for at least one month. This Research Findings begins with estimates for 2009–2015 of the percentage and number of non-elderly adults, ages 18–64, in the U.S. civilian noninstitutionalized population, who were ever uninsured during the calendar year. The Findings then presents "ever uninsured" estimates for 2013 to 2015 for adults in various demographic groups, overall and by state Medicaid expansion status. All differences between estimates discussed in the text are statistically significant at the 0.05 level.

Findings

Between 2009 and 2013, the percentage of non-elderly adults ever uninsured during the year (the "ever uninsured" rate) ranged from 29.0 percent to 30.8 percent. In 2014, the "ever uninsured" rate declined to 27.8 percent (53.1 million adults) from the 2013 rate of 30.8 percent (58.4 million adults). In 2015, the rate declined again to 23.5 percent (45.1 million adults) (figures 1 and 2). The remainder of this Research Findings examines changes in "ever uninsured" rates between 2013 and 2015 for non-elderly adults in various demographic groups, nationally and by state Medicaid expansion status.

Sex
"Ever uninsured" rates for non-elderly men were higher than for women, both overall and in both Medicaid expansion categories in each year from 2013 to 2015 (figures 3 and 4). In 2013, 33.1 percent of men and 28.6 percent of women, nationally, were uninsured at some point during the year. National uninsured rates for both sexes declined in 2014 and then again in 2015.

"Ever uninsured" rates for both men and women and all non-elderly adults were significantly lower in Medicaid expansion than non-expansion states in 2013 and remained lower in 2014 and 2015. In Medicaid expansion states, rates declined for both sexes in 2014 and all non-elderly adults and then again in 2015. In non-expansion states, rates declined for women in both years but only declined for men in 2014. For all non-elderly adults in non-expansion states, "ever uninsured" rates declined in both years.

Age
In 2013, the percentage of non-elderly adults ever uninsured during the calendar year declined with increasing age, both overall and in Medicaid expansion and non-expansion states (figures 5 and 6). At the national level, 39.8, 27.2, and 21.7 percent of adults ages 18–35, 36–54, and 55–64, respectively, were uninsured during 2013. In the following two years, uninsured rates decreased from their 2013 levels in each age group, first in 2014 and then again in 2015.

In Medicaid expansion states, "ever uninsured" rates for adults ages 18–35 and ages 36–54 declined in 2014 and then again in 2015. In non-expansion states, rates declined in 2014 for adults ages 18–35 and declined in 2015 for those ages 55–64. Over this period, the difference in uninsured rates between the youngest (18–35 year olds) and oldest (55–64 year olds) narrowed significantly only in Medicaid expansion states in 2015.

"Ever uninsured" rates were lower in Medicaid expansion than non-expansion states for adults in each age category in 2013. For example, 35.7 and 19.6 percent of adults ages 18–35 and 55–64 were ever uninsured during 2013 in expansion states, compared to 44.8 percent and 24.2 percent in non-expansion states, respectively. Uninsured rates remained lower in expansion than non-expansion states for adults ages 18–35 and 36–54 in both 2014 and 2015. However, for adults ages 55–64, the "ever uninsured" rate was lower in expansion states in 2014 but there was no significant difference in 2015.

Race/ethnicity
In 2013, non-Hispanic white adults (24.2 percent) had a lower "ever uninsured" rate than Hispanic (52.7 percent) and non-Hispanic black adults (37.2 percent) (figures 7 and 8). "Ever uninsured" rates declined in 2014 and then again in 2015 for adults in all racial/ethnic groups, but it wasn't until 2015 that the percentage point difference in "ever uninsured" rates between Hispanic and white adults narrowed significantly.
There was no statistically significant narrowing of rates for black compared to white adults in either year.

Similar to findings at the national level, in Medicaid expansion states, "ever uninsured" rates declined in 2014 and then again in 2015 for adults in each racial/ethnic group. In non-expansion states, declines in "ever uninsured" rates occurred for different groups in different years. For example, rates declined significantly for white adults in 2014 but not 2015 and only declined significantly in 2015 for Hispanic, black, and Asian adults.

In Medicaid expansion states, "ever uninsured" rates for Hispanic adults declined from 48.8 percent in 2013 to 44.9 percent in 2014 and to 35.5 percent in 2015. However, as noted above for the national estimates, it wasnt until 2015 that the difference in rates for Hispanic adults relative to white adults narrowed significantly in Medicaid expansion states compared to both 2013 and 2014. In states that did not expand Medicaid, "ever uninsured" rates for Hispanic adults declined between 2014 and 2015, but remained over 50 percent. Furthermore, there was no statistically significant narrowing of the difference in rates between Hispanic and white adults in non-expansion states over this period.

In Medicaid expansion states, the difference in "ever uninsured" rates between black and white adults narrowed significantly in 2014, but did not narrow in either year in non-expansion states. For Asian and white adults, "ever uninsured" rates were significantly different in 2013 (25.5 percent for Asian adults and 21.2 percent for white adults) but there was no significant difference in either 2014 or 2015. In non-expansion states, "ever uninsured" rates for Asian and white adults were not significantly different in any year from 2013 to 2015.

Educational attainment
Nationally, "ever uninsured" rates in 2013 were lower for adults with higher levels of educational attainment (figures 9 and 10). More than half of non-elderly adults in the lowest education category (51.8 percent) were ever uninsured during 2013, compared with 37.7, 31.1, and 14.9 percent for individuals with a high school diploma or GED, some college, and a college degree or more, respectively. In 2014 and then again in 2015, uninsured rates declined for each education category, except for those with a college degree or more in 2014. Nationally, differences in rates narrowed for those in the highest education group and all three other education categories between 2013 and 2015.

In Medicaid expansion states, "ever uninsured" rates for adults in the lowest education category declined in 2014 and then again in 2015, falling from 48.1 percent in 2013 to 36.9 percent in 2015. Rates also fell in both years for adults with a high school diploma or GED and those with some college education. By 2015, the declines for these groups had narrowed the differences in rates between adults in the highest education group and those in all other educational categories.

In non-expansion states, rates for adults in the lowest education category did not decline significantly and remained above 50 percent in all years. While there were some declines in "ever uninsured" rates over this period for those with a high school diploma or GED and for those with some college education, there was no significant narrowing in differences in rates between adults in the highest educational group and adults in these other categories.

Health status
"Ever uninsured" rates for adults in fair or poor health were higher than for adults in good to excellent health, both overall and in both state Medicaid expansion categories in each year from 2013 to 2015 (figures 11 and 12). Nationally, about 36.8 percent of adults in fair or poor health were ever uninsured during 2013 compared to 29.3 percent of adults in good to excellent health. "Ever uninsured" rates declined for adults in both health status groups in 2014 and then again in 2015.

"Ever uninsured" rates for both health status groups were significantly lower in Medicaid expansion than non-expansion states in each year from 2013 to 2015. In Medicaid expansion states, rates declined in both years for adults in both health status categories. In non-expansion states, however, rates only declined significantly for those in good to excellent health. By 2015, differences in rates between adults in fair or poor health and those in good to excellent health had only narrowed significantly for adults living in Medicaid expansion states.

Chronic conditions
"Ever uninsured" rates for adults with at least one chronic condition were lower than for adults with no chronic conditions, nationally and in both state Medicaid expansion categories in each year from 2013 to 2015 (figures 13 and 14). Nationally, about 26.5 percent of adults with at least one chronic condition were ever uninsured in 2013 compared to 35.6 percent of adults with no chronic conditions. "Ever uninsured" rates declined for adults with and without a chronic condition in 2014 and then again in 2015.

"Ever uninsured" rates for those with and without a chronic condition were significantly lower in Medicaid expansion than non-expansion states in each year from 2013 to 2015. These rates declined from 2013 to 2015 for both chronic condition groups in both Medicaid expansion categories, but differences in rates by the presence of chronic conditions did not narrow in this period, nationally or in either Medicaid expansion category.

Data Source

The estimates shown in this Research Findings for 2013 through 2015 are drawn from analyses conducted by the MEPS staff from files HC-163, HC-171, and HC-174. The 2013 through 2015 files are augmented with information on the person's state of residence and the 2015 file is augmented with a weight that is post-stratified by poverty status to the Current Population Survey. Data for estimates for 2009 through 2012 are drawn from files HC-129, HC-138, HC-147 and HC-155.

Definitions

Age
People were included in the sample if they were between the ages of 18 and 64 throughout the calendar year and present in the MEPS-HC for the entire calendar year. This restriction excludes individuals who were institutionalized, left the country or died during the year and those who joined the household after January. Age is categorized based on the person's age at the end of the calendar year.

Uninsured
People who did not have health insurance coverage for at least one month in the calendar year were classified as uninsured. To be considered insured people would need to be covered by any of the following sources: Medicaid, Medicare, TRICARE (Armed Forces-related coverage), other public hospital/physician programs, private hospital/physician insurance (including Medigap coverage) or insurance purchased through health insurance Marketplaces. People covered only by non-comprehensive State-specific programs (e.g., Maryland Kidney Disease Program) or private single service plans such as coverage for dental or vision care only, or coverage for accidents or specific diseases, were considered uninsured.

Race/ethnicity/nativity
Classification by race/ethnicity was based on information reported for each family member. First, respondents were asked if the person's main national origin or ancestry was Puerto Rican; Cuban; Mexican, Mexican-American, or Chicano; other Latin American; or other Spanish. All persons whose main national origin or ancestry was reported in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. All other persons were classified according to their reported race. For this analysis, the following classification by race/ethnicity was used: Hispanic (any race), black non-Hispanic only, white non-Hispanic only, and Asian non-Hispanic only. Individuals who did not fit into one of these categories were excluded from the analysis.

Education
Information on the highest level of schooling completed or the highest degree received by a person was asked in the first round the person was included in the MEPS-HC. The categories included in this Research Findings include 12 or fewer years of school (no high school diploma), high school diploma or GED, some college, and a college degree or more.

Health status
Information from three rounds of the MEPS-HC in each calendar year was used to classify individuals by perceived health status. In every round, the respondent was asked the following question to rate the health of every member of the family: "In general, compared to other people of (PERSON)'s age, would you say that (PERSON)'s health is excellent, very good, good, fair, or poor?" Individuals were classified as being in "fair/poor" health if they were reported to be in fair or poor health at any time during these three MEPS-HC rounds. Individuals were classified as being in "excellent, very good, good" health if they were reported to be in excellent, very good or good health in each of these three rounds.

Chronic conditions
Adults who were reported as having one or more diagnosed chronic conditions were defined as those with: active asthma, arthritis, diabetes, emphysema, heart disease, high blood pressure, high cholesterol, bronchitis or stroke. Active asthma was defined as adults who were ever told they had asthma and who were reported to still have asthma or had an asthma attack in the past 12 months. Arthritis includes respondents with pain, aching, stiffness or swelling around a joint in the past 12 months. Bronchitis includes respondents who were reported as having chronic bronchitis in the past 12 months. High blood pressure was defined as adults who were reported being told on two or more occasions they had high blood pressure. Heart disease was created using four questions on whether the person was ever told she or he had: coronary heart disease, angina, a heart attack, or any other kind of heart condition or heart disease. Adults who had diabetes, emphysema, high cholesterol, and stroke were defined as adults who were reported as ever being told they had those conditions.

Medicaid expansion states
When analyzing 2013 and 2014 data, this Research Findings defined Medicaid expansion states as those states that implemented the expansion at any time during calendar year 2014. For these years, Medicaid expansion states included Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and West Virginia. For 2015, Medicaid expansion states included all states that expanded during 2014 in addition to the three states that expanded during 2015: Alaska, Indiana, and Pennsylvania.

About MEPS-HC

MEPS-HC is a nationally representative longitudinal survey that collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian noninstitutionalized population. It is co-sponsored by the Agency for Healthcare Research and Quality and the National Center for Health Statistics.

For more information about MEPS, call the MEPS information coordinator at AHRQ (301-427-1406) or visit the MEPS Web site at http://www.meps.ahrq.gov/.

Vistnes, J. and Lipton, B. The Uninsured in America, 2013-2015: Estimates for Non-Elderly
Adults Uninsured Throughout Each Calendar Year, by Selected Population Sub-groups and
State Medicaid Expansion Status. Research Findings #35. August 2017. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf35/rf35.shtml

Suggested Citation

Lipton, B. and Vistnes, J. Ever Uninsured During the Calendar Year, 2013–2015: Estimates of Non-Elderly Adults Ever Uninsured During Each Calendar Year, by Selected Population Sub-groups and State Medicaid Expansion Status. Research Findings #37. August 2017. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.meps.ahrq.gov/mepsweb/data_files/publications/rf37/rf37.shtml

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